1275666315 NPI number — JAECHAN PARK D.D.S.

Table of content: JAECHAN PARK D.D.S. (NPI 1275666315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275666315 NPI number — JAECHAN PARK D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
JAECHAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275666315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
614 INVERNESS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FULLERTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92835-2776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-454-0159
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15201 S WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90249-4314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-400-7705
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  49972 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1687022 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: G92988-01 . This is a "DENTICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1581480 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: B49972-01 . This is a "HEALTHY FAMILY" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: D49972 . This is a "DENTICAL-RENDERING ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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